Correspondence

Patient Access to Magnetic Resonance Imaging Centers in Orange County, California

N Engl J Med 1993; 328:884-885March 25, 1993

Article

To the Editor:

It is becoming increasingly common for physicians to invest in free-standing health care businesses to which they refer their patients but at which they do not practice. These arrangements, known as joint ventures, include a wide variety of diagnostic and therapeutic services; a salient example is centers offering magnetic resonance imaging (MRI). Discussion of the appropriateness and ethics of these arrangements has been widespread. Opponents of this practice say that referring physicians have a direct conflict of interest when they are owners of businesses to which patients are referred. The main argument of proponents is that investment by physicians enhances patients' access to care.

Orange County, California, has 2.4 million residents, 798 square miles, and 41 MRI centers (personal communications from community radiologists and industry representatives). By comparison, Canada has 27 million residents, 4 million square miles, and 22 MRI centers.1 In Orange County, nine MRI centers are based at six hospitals (one hospital has three units, and another has two). Fourteen centers are mobile. Seventeen MRI units are “free-standing,” some directly adjacent to hospitals. These free-standing units are all independently owned; physicians are investors in almost all of them.

To test the hypothesis that free-standing MRI centers in Orange County increase patients' access, I conducted the following survey. Over a three-month period, I randomly called all 17 free-standing centers, posing as three persons. First, I called as a patient with a minor orthopedic problem, referred by my physician for an MRI. When asked about insurance, I identified my own plan (Prudential High Option Health Care). I was offered an appointment at any time; 48 hours was the longest delay I encountered. Virtually every unit offered next-day service.

I made the next two series of calls posing as a patient referred by my physician with the diagnosis of a possible brain tumor and the recommendation that I undergo MRI as soon as possible. When questioned about my insurance status in the second series of calls, I stated that Medi-Cal (Medicaid) was my payer. Representatives of 6 of the 17 centers said that they could schedule such a study within two to three weeks if my physician would be willing to complete the extensive paperwork necessary to obtain special authorization from Medi-Cal. Representatives of the other 11 units stated that they did not accept Medi-Cal coverage under any circumstances.

In the third series of calls, I stated that I was uninsured and had no funds immediately available to pay for the MRI. None of the 17 centers would accept a patient without funds; under the most satisfactory arrangement I was offered, I would have to pay $500 cash before the procedure and show “evidence of ability to pay the remainder of the $500 to $700 due promptly.”

As both the patient with Medi-Cal coverage and the patient without funds, I asked for an alternative way to obtain the test. Most of the representatives said they were unaware of any; the only suggestion I received was to try “UCI” -- the University of California, Irvine, Medical Center, the not-for-profit hospital in which I work. The MRI unit at the medical center is owned by American Medical International, a for-profit organization, and provides services for the large number of Medicaid and uninsured patients cared for at the institution. The full use of this unit precludes acceptance of referrals of patients financially screened out at other MRI centers in the county.

Despite the plethora of MRI centers in Orange County, access is severely limited for both Medicaid patients and patients who lack health insurance. These findings cast serious doubt on the argument that joint ventures in MRI improve access to care. I suspect that the situation in Orange County is not unique. The Clinton administration and state governments should consider legislation to prohibit such joint ventures and to ensure that when medically indicated, sophisticated forms of technology such as MRI are available to patients regardless of their insurance status.

Beverly C. Morgan, M.D.
University of California, Irvine, Medical Center, Orange, CA 92668

1 References

1. 1

   Canadian Coordinating Office for Health Care Technology Assessment, Ottawa, Canada. Technology Brief, issue 5.1, October 1992.
   

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   (1993) More on Patient Access to Magnetic Resonance Imaging Centers. New England Journal of Medicine 329:6, 435-436
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   Steinberg, Earl P., . (1993) Magnetic Resonance Coronary Angiography -- Assessing an Emerging Technology. New England Journal of Medicine 328:12, 879-880
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